Dr Salerno cited data from the PRIME II study (Fyles et al, N Engl J Med. 2004;351:963-970), which looked at women aged 65 years and older, and also from the CALGB 9343 study (Hughes et al, J Clin Oncol. 2013;31:2382-2387) and the NSABP B-21 study (Kunkler et al, Lancet Oncol. 2015), both of which included women aged 70 years or older with small cancers, negative nodes, and negative margins, and who were ER/PR positive. The results from all three of these studies showed no survival detriment to forgoing radiation in this population, she noted.

“There are a lot of studies being done now that are going beyond using age as the sole criterion and are looking at features of tumor biology and then moving towards better ways of stratifying recurrence risk. I think those trials are going to be very informative and take us beyond what we are currently using,” Dr Salerno said.

Regional Nodal Irridation for Some?

The 2016 NCCN breast cancer guidelines also address the issue of which patients need regional nodal irradiation, and to what extent, she said.

“Several studies are showing a benefit with regional nodal radiation for recurrence and disease-free survival but not for overall survival, so we know there’s a benefit to radiation,” Dr Salerno said.

“We are working to best determine who does or does not need that treatment. I don’t want people to take home that this is a blanket statement for every single patient to be treated, but you have to strongly consider this treatment based on data we now have, particularly from the EBCTCG meta-analysis [Early Breast Cancer Trialists Collaborative Group, Lancet. 2014;383:2127-2135] in patients who are one to three nodes positive,” she said.

“The areas to be treated in regional nodal irradiation include the supraclavicular nodes, the infraclavicular nodes, the axillary bed at risk, and the internal mammary lymph nodes. These are the nodal areas that were included in the aforementioned studies,” she said.

“When treating the internal mammary nodes, especially on the left side, the radiation oncologist needs to think about heart and lung dose,” Dr Salerno said.

“We are trying very hard with our modern techniques to target what needs to be treated fully and minimize treating the remainder of the patient that does not need to be treated, in particular, heart and lung. We can tailor our therapies to help mitigate the side effects of treatment,” she said.

Dr Salerno added that the newer trend of the NCCN guidelines is to refine its language regarding recommendations for management of disease instead of making large changes. She said that it was nice to hear another expert talk about ‘tweeks and refinements’ to the guidelines as opposed to the dramatic rearrangements seen in past years, and increasingly, this is going to be the way going forward, she predicted.

Approached for comment, William J. Gradishar, MD, Betsy Bramsen Professor of Breast Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, told Medscape Medical News that the updated guidelines for the management of breast cancer bring greater clarity to the options that patients now have.
Dr William Gradishar
“The updates include shorter durations of radiation therapy, which is now considered a first choice for many patients. Additionally, the role of accelerated partial breast irradiation and the circumstances where radiation can be avoided were discussed. A large part of Dr Salerno’s discussion also focused on the clinical scenarios in which regional node basins should be irradiated and her review of the data that support those recommendations in early-stage breast cancer,” he said.

The NCCN guidelines are also striving to help clinicians personalize their management of breast cancer patients, noted Tuya Pal, MD, from Moffitt Cancer Center, Tampa, Florida.
Dr Tuya Pal
“As new data become available, there continue to be efforts to personalize treatments to maximize patient benefit while minimizing risks. This results in refinement, rather than drastic changes to existing guidelines,” Dr Pal told Medscape Medical News.

Robert J. Morgan Jr, MD, codirector of the Gynecological Cancers Program at the City of Hope, Duarte, California, agreed that the refinements to the 2016 NCCN guidelines for breast cancer will lead to more efficient and less toxic treatment.

“All NCCN guidelines are updated at least annually with meetings or conference calls of the respective committees, or more often as necessary to make certain the guidelines reflect the most important and recently published information regarding cancer treatment,” Dr Morgan told Medscape Medical News.

“The updates to the breast cancer guidelines reflect this ongoing effort, which is also performed by all of the guideline subcommittees for every tumor type. Many of the changes to the guidelines will be the result of the demonstration of safer, less toxic treatment approaches as they are compared to standard treatment approaches in clinical trials,” he said.

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Dr. Ricardo Vicario| Plastic Surgery and Aesthetic Medicine 1 hour ago
Thank you for your excellent article, highlight the reduction of the total time of treatment and that the acute toxicity and late are low, without doubt a great achievement thanks to hipofraccionamiento in patients with low recurrence rate. With this technique, the duration of the therapy is reduced, which represents an improvement in the quality of life of the patients and a significant reduction of the total cost of the treatment. The aesthetic results are valued as excellent by the patients in more than 70 percent. I congratulate you for your great study.